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My provider has hired someone to take her handwritten notes and enter them into the EHR. This employee is not in the exam room and is completing the note after the visit. This is a family practice provider. I am the biller/coder. Does anyone know if this is acceptable or the guidelines for this. I have been reading about scribes, but it seems the scribe is supposed to be in the exam room.
 

thomas7331

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My provider has hired someone to take her handwritten notes and enter them into the EHR. This employee is not in the exam room and is completing the note after the visit. This is a family practice provider. I am the biller/coder. Does anyone know if this is acceptable or the guidelines for this. I have been reading about scribes, but it seems the scribe is supposed to be in the exam room.
It sounds like this person is acting as a transcriptionist rather than a scribe in the usual sense of the word, but either way, it is acceptable as long as the provider is the one who is authenticating it to attest that it is accurate.
Per CMS:

What if I use a scribe when documenting medical record entries?
Regardless of who writes a medical record entry, you must sign the entry to authenticate it adequately documents the care you provided or ordered. It is unnecessary to document who transcribed the entry.
 

TThivierge

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My provider has hired someone to take her handwritten notes and enter them into the EHR. This employee is not in the exam room and is completing the note after the visit. This is a family practice provider. I am the biller/coder. Does anyone know if this is acceptable or the guidelines for this. I have been reading about scribes, but it seems the scribe is supposed to be in the exam room.
Hi

Just to let you know if doc does get a medical scribe...they must put their name on the medical record. Transcriptionst's name is not necessary.the scribes we had were right in room with doc when he did his exam or right after then typed right into system or laptop his notes.

I hope this helps you


Lady T
 
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